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False Alarm on Abortion

ABORTION financing has become an important stumbling block in negotiations over health care reform. An amendment sponsored by Representative Bart Stupak, Democrat of Michigan, which was added to the House bill at the last minute, would prohibit both government-run insurance plans and any private insurance plans purchased with government subsidies from covering abortions.

The amendment quickly led to a burst of rhetoric and lobbying on both sides of the abortion debate. But this public battle exaggerates the extent to which the Stupak amendment would really change things for women seeking abortions. And, at the same time, it obscures the other benefits that expanded health insurance coverage could bring to women’s reproductive health. Ultimately, providing greater access to family planning could significantly reduce the total number of unintended pregnancies.

The Stupak amendment’s effect on any individual woman’s insurance coverage for abortion depends on what kind of insurance she has now. About 12 percent of the 62 million American women of childbearing age — ages 15 to 44 — are now covered by public insurance plans like Medicaid. For them there will be no change because current law already prohibits the use of federal funds to cover abortion costs.

Likewise, the amendment would change nothing for women who now have no insurance — about 20 percent of women of childbearing age.

The women whose abortion coverage would be at risk are those who are covered by private insurance — some 42 million women aged 15 to 44. Insurers could decide to drop all abortion coverage in order to ensure their eligibility to participate in public insurance exchanges, where many Americans are expected to purchase insurance if health reform legislation passes. But women who have private insurance are not as likely as women with no insurance or public insurance to have abortions. Privately insured women tend to be older, with higher family income, and women in these groups are much less prone to seek abortions.

The abortion rate of women in poverty is four times that of women above 300 percent of the poverty level. Only six percent of women of childbearing age with private health insurance live in poverty; 62 percent have incomes above 300 percent of the poverty line.

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Even if women with private health insurance find themselves seeking an abortion, the out-of-pocket cost for the vast majority of them is not that high relative to their income. In general, 89 percent of abortions are performed in the first trimester; these non-hospital procedures cost an average of around $400.

The small group of women who decide to abort after their first trimester — perhaps for reasons of fetal health — could potentially be affected more seriously, as these abortions are considerably more expensive. Yet the women who undergo second-trimester abortions are unlikely to be covered by private insurance now; nearly two-thirds of them have family incomes below 200 percent of the poverty level.

What is being overlooked in this debate is the benefit to women’s reproductive health that would most likely occur if insurance access were expanded. Currently, 89 percent of private health insurance plans cover contraceptive services. Presumably, if health care reform provided insurance to more women, those who gained coverage would receive family planning services as well. Research on expanded Medicaid coverage that I have done with a colleague using data from 1990 to 2003 found that it reduced unintended childbearing by 9 percent. Our data indicate that this reduction was attributable to greater use of contraception.

This suggests that health care reform could lead to a substantial reduction in unintended fertility. Consider that there are 12.4 million uninsured women of childbearing age. Suppose that health care reform ended up providing health insurance for 10 million of them. Each year, roughly 7 percent of all women this age give birth, amounting to about 700,000 births to this group of women. If their rate of fertility were cut by 9 percent, then 63,000 unintended births could be avoided if health care reform is enacted.

I do not mean to understate the importance of the abortion debate taking place. Yet this debate should not overshadow the tangible benefits to women’s reproductive health that could be brought about by expanded insurance coverage.

Phillip B. Levine, a professor of economics at Wellesley College, is the author of “Sex and Consequences: Abortion, Public Policy and the Economics of Fertility.”

A version of this op-ed appears in print on November 25, 2009, on Page A31 of the New York edition with the headline: False Alarm On Abortion. Today's Paper|Subscribe